Medical Records and Malpractice: Why Changes Can Hurt Your Defense

When faced with a medical malpractice claim, a physician’s most important line of defense is the medical record of their interactions with the patient. A properly maintained medical record system serves as a golden shield, providing evidence that the physician adhered to best practice standards throughout the patient’s care. 

Conversely, a medical record altered after a claim can become the sword on which a physician falls, undermining their defense and damaging their credibility. Maintaining accurate, unaltered records is essential, not only for defending against claims but also for protecting a physician’s reputation and professional integrity.

What is Spoliation of Evidence?

Spoliation is the legal term used to describe the alteration of a medical record after a physician has been informed of a possible medical malpractice claim. It refers to the destruction, hiding, alteration, or withholding of information that is crucial to a lawsuit. 

In the context of medical malpractice cases, spoliation is particularly significant because it can severely undermine a physician’s defense. When a court discovers that a physician has taken the time and effort to alter evidence, it may conclude that this action indicates an attempt to hide a significant liability. Such conclusions can damage the physician’s credibility and lead to negative repercussions in court, making it clear that preserving the integrity of medical records is essential for an effective defense.

Why Altering Medical Records Can Damage Your Defense

Altering medical records poses significant legal and reputational risks for physicians. When a physician changes, deletes, or otherwise tampers with records, courts may interpret these actions as evidence of liability, suggesting an attempt to cover up negligence or wrongdoing.

This perception can lead to severe consequences, including higher damages awarded to the plaintiff. The discovery of altered records can also seriously harm a physician’s reputation, damaging relationships with patients and colleagues alike, and potentially resulting in disciplinary actions from medical boards.

Common Reasons Physicians Alter Records (and Why They Shouldn’t)

Physicians may feel compelled to alter records for several reasons, including the desire to:

• Omit Negative Outcomes: Deleting or modifying records related to adverse patient outcomes to avoid implications of malpractice.
• Add Justifications: Inserting explanations or justifications that weren’t documented at the time of care.

While these actions might seem like a quick fix, they are ultimately counterproductive. The risks of spoliation far outweigh any short-term benefits, as:

• Alterations can be discovered through forensic analysis, especially in electronic records.
• Such actions may lead a jury to view the physician as dishonest, significantly weakening their defense.
• Increased likelihood of a guilty verdict can result in higher financial penalties.

Electronic Medical Records (EMRs) and the Risk of Detection

Electronic medical records are particularly risky to alter due to their traceable digital footprints. Any modifications made in EMRs can be tracked, revealing time stamps and any deletions or additions. This makes it easy for digital forensics to uncover any alterations, which can significantly impact a physician’s defense in malpractice cases.

Best Practices for Maintaining Medical Records in Case of a Malpractice Claim

To preserve accurate and thorough records, physicians should follow these guidelines:

• Document all patient interactions promptly and comprehensively.
• Avoid making changes to existing records; instead, add clarifying notes if necessary.
• Use standardized templates to ensure consistency and completeness.
• Proactive record-keeping habits, such as regular audits of documentation practices, can help protect physicians if a claim arises.
• Learn more about Malpractice Insurance 101

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*This article has been updated with new information